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Wu HL, Zhou HX, Chen LM, Wang SS. Metronomic chemotherapy in cancer treatment: new wine in an old bottle. Theranostics 2024; 14:3548-3564. [PMID: 38948068 PMCID: PMC11209710 DOI: 10.7150/thno.95619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/26/2024] [Indexed: 07/02/2024] Open
Abstract
Over the past two decades, metronomic chemotherapy has gained considerable attention and has demonstrated remarkable success in the treatment of cancer. Through chronic administration and low-dose regimens, metronomic chemotherapy is associated with fewer adverse events but still effectively induces disease control. The identification of its antiangiogenic properties, direct impact on cancer cells, immunomodulatory effects on the tumour microenvironment, and metabolic reprogramming ability has established the intrinsic multitargeted nature of this therapeutic approach. Recently, the utilization of metronomic chemotherapy has evolved from salvage treatment for metastatic disease to adjuvant maintenance therapy for high-risk cancer patients, which has been prompted by the success of several substantial phase III trials. In this review, we delve into the mechanisms underlying the antitumour effects of metronomic chemotherapy and provide insights into potential combinations with other therapies for the treatment of various malignancies. Additionally, we discuss health-economic advantages and candidates for the utilization of this treatment option.
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Affiliation(s)
| | | | | | - Shu-sen Wang
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou 510060, China
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2
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Oral tegafur-uracil as a metronomic therapy in stage IVa and IVb cancer of the oral cavity. Am J Otolaryngol 2021; 42:103156. [PMID: 34242883 DOI: 10.1016/j.amjoto.2021.103156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/14/2021] [Accepted: 06/19/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE This study aimed to evaluate the impact of accumulated oral tegafur-uracil (UFUR) as maintenance chemotherapy on overall survival (OS) and disease-free survival (DFS) rates after definitive treatment for non-distant metastatic stage IV cancer of the oral cavity. MATERIALS AND METHODS This retrospective, hospital center-based study analyzed data of patients diagnosed with stage IVa and IVb cancer of the oral cavity who underwent surgical resection and concurrent chemoradiotherapy (CCRT) obtained from a database between October 2008 and December 2014. RESULTS Forty-two patients were treated with CCRT (non-UFUR group); the remaining 51 patients received the same regimen, followed by additional oral UFUR (UFUR group). For all study patients, the 3-year DFS rates were 53.05% and 35.41% in the UFUR and non-UFUR groups, respectively (p = 0.011), while the 3-year OS rates were 74.96% and 48.47%, respectively (p = 0.001). CONCLUSIONS Adding UFUR to CCRT significantly improved the DFS and OS rates in patients with non-distant metastatic stage IV cancer of the oral cavity.
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3
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Metronomic chemotherapy for patients with metastatic breast cancer: Review of effectiveness and potential use during pandemics. Cancer Treat Rev 2020; 89:102066. [PMID: 32769038 DOI: 10.1016/j.ctrv.2020.102066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
Metronomic chemotherapy (M-CT) is defined as dose dense administration of chemotherapy at lower doses than maximum tolerated dose but at shorter free intervals, to obtain a near continuous exposure of cancer cells to those potentially effective drugs. M-CT is a useful strategy to obtain response, overcome resistance and reduce side effects, with low costs. This review will focus on the use of M-CT in advanced breast cancer (ABC). Cytostatic and cytotoxic effect on cancer cells, the anti-angiogenic and the immunomodulatory effects are its main mechanisms of actions. Many clinical trials proved the efficacy and tolerability of different monotherapies and combinations of chemotherapeutic agents administered in metronomic doses and frequencies in ABC. M-CT is a reasonable option for second and later lines of chemotherapy in metastatic breast cancer including those with prior anthracycline or taxane exposure, older patients and patients with comorbidities, and even as first-line in certain groups of patients. The acceptable efficacy and low toxicity of oral metronomic chemotherapy makes it a reasonable option during COVID-19 pandemic as well as in the post-COVID era which is projected to last for some time.
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4
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Pramanik R, Bakhshi S. Metronomic therapy in pediatric oncology: A snapshot. Pediatr Blood Cancer 2019; 66:e27811. [PMID: 31207063 DOI: 10.1002/pbc.27811] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Abstract
Metronomic chemotherapy transitioned from the bench to bedside in the early 2000s and since then has carved a niche for itself in pediatric oncology. It has been used solely or in combination with other modalities such as radiotherapy, maximum tolerated dose chemotherapy, and targeted agents in adjuvant, palliative, as well as maintenance settings. No wonder, the resulting medical literature is extremely heterogeneous. In this review, the authors review and synthesize the published literature in pediatric metronomics giving a glimpse of its history, varied applications, and evolution of this genre of chemotherapy in pediatric cancers. Limitations, future prospects, and grey areas are also highlighted.
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Affiliation(s)
- Raja Pramanik
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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5
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Chen J, Huang W, Ho C, Chao T, Lee J. Evaluation of oral tegafur‐uracil as metronomic therapy following concurrent chemoradiotherapy in patients with non‐distant metastatic TNM stage IV nasopharyngeal carcinoma. Head Neck 2019; 41:3775-3782. [DOI: 10.1002/hed.25904] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 06/05/2019] [Accepted: 07/22/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jia‐Hong Chen
- Division of Hematology/Oncology, Department of MedicineTri‐Service General Hospital, National Defense Medical Center Taipei Taiwan
- Graduate Institute of Clinical Medicine, College of MedicineTaipei Medical University Taipei Taiwan
| | - Wen‐Yen Huang
- Department of Radiation Oncology, Tri‐Service General HospitalNational Defense Medical Center Taipei Taiwan
| | - Ching‐Liang Ho
- Division of Hematology/Oncology, Department of MedicineTri‐Service General Hospital, National Defense Medical Center Taipei Taiwan
| | - Tsu‐Yi Chao
- Graduate Institute of Clinical Medicine, College of MedicineTaipei Medical University Taipei Taiwan
- Division of Hematology and Oncology, Department of MedicineTaipei Medical University, Shuang Ho Hospital New Taipei City Taiwan
| | - Jih‐Chin Lee
- Department of Otolaryngology–Head and Neck SurgeryTri‐Service General Hospital, National Defense Medical Center Taipei Taiwan
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6
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Mahmud F, Jeon OC, Alam F, Maharjan R, Choi JU, Park J, Lee S, Park JW, Lee DS, Byun Y. Oral pemetrexed facilitates low-dose metronomic therapy and enhances antitumor efficacy in lung cancer. J Control Release 2018; 284:160-170. [DOI: 10.1016/j.jconrel.2018.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/12/2018] [Indexed: 01/03/2023]
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7
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Nicolas A, Carré M, Pasquier E. Metronomics: Intrinsic Anakoinosis Modulator? Front Pharmacol 2018; 9:689. [PMID: 29988614 PMCID: PMC6026805 DOI: 10.3389/fphar.2018.00689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/07/2018] [Indexed: 01/20/2023] Open
Affiliation(s)
- André Nicolas
- Service d'Hématologie et Oncologie Pédiatrique, Hôpital pour Enfants de La Timone, AP-HM, Marseille, France
| | - Manon Carré
- Aix-Marseille Univ., Centre National de la Recherche Scientifique, INSERM, Institut Paoli Calmettes, CRCM, Marseille, France
| | - Eddy Pasquier
- Aix-Marseille Univ., Centre National de la Recherche Scientifique, INSERM, Institut Paoli Calmettes, CRCM, Marseille, France
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8
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Chung SW, Kweon S, Lee BS, Kim GC, Mahmud F, Lee H, Cho YS, Choi JU, Jeon OC, Kim JW, Kim SW, Kim IS, Kim SY, Byun Y. Radiotherapy-assisted tumor selective metronomic oral chemotherapy. Int J Cancer 2017. [DOI: 10.1002/ijc.30842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Seung Woo Chung
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University; Seoul South Korea
| | - Seho Kweon
- Department of Molecular Medicine and Biopharmaceutical Sciences; Graduate School of Convergent Science and Technology, Seoul National University; Seoul South Korea
| | - Beom Suk Lee
- Biomedical Research Institute, Korea Institute of Science and Technology; Seoul South Korea
- Department of Otolaryngology; Asan Medical Center, University of Ulsan College of Medicine; Seoul South Korea
| | - Gui Chul Kim
- Department of Otolaryngology; Asan Medical Center, University of Ulsan College of Medicine; Seoul South Korea
| | - Foyez Mahmud
- Department of Molecular Medicine and Biopharmaceutical Sciences; Graduate School of Convergent Science and Technology, Seoul National University; Seoul South Korea
| | - Hanul Lee
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University; Seoul South Korea
| | - Young Seok Cho
- Department of Molecular Medicine and Biopharmaceutical Sciences; Graduate School of Convergent Science and Technology, Seoul National University; Seoul South Korea
| | - Jeong Uk Choi
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University; Seoul South Korea
| | | | - Ji Won Kim
- Department of Otolaryngology; Asan Medical Center, University of Ulsan College of Medicine; Seoul South Korea
| | - Seong Who Kim
- Department of Biochemistry and Molecular Biology; Asan Medical Center, College of Medicine, University of Ulsan; Seoul South Korea
| | - In-San Kim
- Biomedical Research Institute, Korea Institute of Science and Technology; Seoul South Korea
- KU-KIST Graduate School of Converging Science and Technology, Korea University; Seoul South Korea
| | - Sang Yoon Kim
- Department of Otolaryngology; Asan Medical Center, University of Ulsan College of Medicine; Seoul South Korea
| | - Youngro Byun
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University; Seoul South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences; Graduate School of Convergent Science and Technology, Seoul National University; Seoul South Korea
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9
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Biziota E, Mavroeidis L, Hatzimichael E, Pappas P. Metronomic chemotherapy: A potent macerator of cancer by inducing angiogenesis suppression and antitumor immune activation. Cancer Lett 2016; 400:243-251. [PMID: 28017892 DOI: 10.1016/j.canlet.2016.12.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/09/2023]
Abstract
Metronomic chemotherapy is a low dosing treatment strategy that attracts growing scientific and clinical interest. It refers to dense and uninterrupted administration of low doses of chemotherapeutic agents (without prolonged drug free intervals) over extended periods of time. Cancer chemotherapy is conventionally given in cycles of maximum tolerated doses (MTD) with the aim of inducing maximum cancer cell apoptosis. In contrast, the primary target of metronomic chemotherapy is the tumor's neovasculature. This is relevant to the emerging concept that tumors exist in a complex microenvironment of cancer cells, stromal cells and supporting vessels. In addition to its anti-angiogenetic properties, metronomic chemotherapy halts tumor growth by activating anti-tumor immunity, thus decreasing the acquired resistance to conventional chemotherapy. Herein, we present a review of the literature that provides a scientific basis for the merits of chemotherapy when administered on a metronomic schedule.
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Affiliation(s)
- Eirini Biziota
- Department of Medical Oncology, University Hospital of Evros, Alexandroupolis, 68 100, Greece.
| | - Leonidas Mavroeidis
- Department of Pharmacology, Faculty of Medicine, School of Life Sciences, University of Ioannina, Ioannina, 451 10, Greece.
| | | | - Periklis Pappas
- Department of Pharmacology, Faculty of Medicine, School of Life Sciences, University of Ioannina, Ioannina, 451 10, Greece.
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10
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Rajasekaran T, Ng QS, Tan DSW, Lim WT, Ang MK, Toh CK, Chowbay B, Kanesvaran R, Tan EH. Metronomic chemotherapy: A relook at its basis and rationale. Cancer Lett 2016; 388:328-333. [PMID: 28003122 DOI: 10.1016/j.canlet.2016.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/07/2016] [Accepted: 12/09/2016] [Indexed: 11/16/2022]
Abstract
Metronomic administration of chemotherapy has long been recognized as having a different biological effect from maximal tolerated dose (MTD) administration. Preclinical studies have demonstrated these differences quite elegantly and many clinical trials have also demonstrated reproducible activity albeit small, in varied solid malignancies even in patients who were heavily pretreated. However, the concept of metronomic chemotherapy has been plagued by lack of a clear definition resulting in the published literature that is rather varied and confusing. There is a need for a definition that is mechanism(s)-based allowing metronomics to be distinguished from standard MTD concept. With significant advances made in understanding cancer biology and biotechnology, it is now possible to attain that goal. What is needed is both a concerted effort and adequate funding to work towards it. This is the only way for the oncology community to determine how metronomic chemotherapy fits in the overall cancer management schema.
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Affiliation(s)
| | - Quan-Sing Ng
- Division of Medical Oncology, National Cancer Centre, Singapore.
| | | | - Wan-Teck Lim
- Division of Medical Oncology, National Cancer Centre, Singapore.
| | - Mei-Kim Ang
- Division of Medical Oncology, National Cancer Centre, Singapore.
| | - Chee-Keong Toh
- Division of Medical Oncology, National Cancer Centre, Singapore.
| | - Balram Chowbay
- Divsion of Medical Sciences, Laboratory of Clinical Pharmacology, National Cancer Centre, Singapore.
| | | | - Eng-Huat Tan
- Division of Medical Oncology, National Cancer Centre, Singapore.
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11
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Abu Lila AS, Ishida T. Metronomic chemotherapy and nanocarrier platforms. Cancer Lett 2016; 400:232-242. [PMID: 27838415 DOI: 10.1016/j.canlet.2016.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 10/30/2016] [Accepted: 11/02/2016] [Indexed: 12/12/2022]
Abstract
The therapeutic concept of administering chemotherapeutic agents continuously at lower doses, relative to the maximum tolerated dose (MTD) without drug-free breaks over extended periods -known as "metronomic chemotherapy"- is a promising approach for anti-angiogenic cancer therapy. In comparison with MTD chemotherapy regimens, metronomic chemotherapy has demonstrated reduced toxicity. However, as a monotherapy, metronomic chemotherapy has failed to provide convincing results in clinical trials. Therapeutic approaches including combining the anti-angiogenic "metronomic" therapy with conventional radio-/chemo-therapy and/or targeted delivery of chemotherapeutic agents to tumor tissues via their encapsulation with nanocarrier-based platforms have proven to potentiate the overall therapeutic outcomes. In this review, therefore, we focused on the mutual contribution made by nanoscale drug delivery platforms to the therapeutic efficacy of metronomic-based chemotherapy. In addition, the influence that the dosing schedule has on the overall therapeutic efficacy of metronomic chemotherapy is discussed.
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Affiliation(s)
- Amr S Abu Lila
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Medical Biosciences, Tokushima University, 1-78-1, Sho-machi, Tokushima 770-8505, Japan; Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt; Department of Pharmaceutics, Faculty of Pharmacy, Hail University, Hail 2440, Saudi Arabia
| | - Tatsuhiro Ishida
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Medical Biosciences, Tokushima University, 1-78-1, Sho-machi, Tokushima 770-8505, Japan.
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12
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An in vitro assessment of liposomal topotecan simulating metronomic chemotherapy in combination with radiation in tumor-endothelial spheroids. Sci Rep 2015; 5:15236. [PMID: 26468877 PMCID: PMC4606561 DOI: 10.1038/srep15236] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 09/02/2015] [Indexed: 12/31/2022] Open
Abstract
Low dose metronomic chemotherapy (LDMC) refers to prolonged administration of low dose chemotherapy designed to minimize toxicity and target the tumor endothelium, causing tumor growth inhibition. Topotecan (TPT) when administered at its maximum tolerated dose (MTD) is often associated with systemic hematological toxicities. Liposomal encapsulation of TPT enhances efficacy by shielding it from systemic clearance, allowing greater uptake and extended tissue exposure in tumors. Extended release of TPT from liposomal formulations also has the potential to mimic metronomic therapies with fewer treatments. Here we investigate potential toxicities of equivalent doses of free and actively loaded liposomal TPT (LTPT) and compare them to a fractionated low dose regimen of free TPT in tumor-endothelial spheroids (TES) with/without radiation exposure for a prolonged period of 10 days. Using confocal microscopy, TPT fluorescence was monitored to determine the accumulation of drug within TES. These studies showed TES, being more reflective of the in vivo tumor microenvironment, were more sensitive to LTPT in comparison to free TPT with radiation. More importantly, the response of TES to low-dose metronomic TPT with radiation was comparable to similar treatment with LTPT. This TES study suggests nanoparticle formulations designed for extended release of drug can simulate LDMC in vivo.
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13
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14
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Kareva I, Waxman DJ, Lakka Klement G. Metronomic chemotherapy: an attractive alternative to maximum tolerated dose therapy that can activate anti-tumor immunity and minimize therapeutic resistance. Cancer Lett 2014; 358:100-106. [PMID: 25541061 DOI: 10.1016/j.canlet.2014.12.039] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 12/11/2022]
Abstract
The administration of chemotherapy at reduced doses given at regular, frequent time intervals, termed 'metronomic' chemotherapy, presents an alternative to standard maximal tolerated dose (MTD) chemotherapy. The primary target of metronomic chemotherapy was originally identified as endothelial cells supporting the tumor vasculature, and not the tumor cells themselves, consistent with the emerging concept of cancer as a systemic disease involving both tumor cells and their microenvironment. While anti-angiogenesis is an important mechanism of action of metronomic chemotherapy, other mechanisms, including activation of anti-tumor immunity and a decrease in acquired therapeutic resistance, have also been identified. Here we present evidence supporting a mechanistic explanation for the improved activity of cancer chemotherapy when administered on a metronomic, rather than an MTD schedule and discuss the implications of these findings for further translation into the clinic.
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Affiliation(s)
- Irina Kareva
- Newman Lakka Institute, Floating Hospital for Children at Tufts Medical Center, Boston, MA 02111; Mathematical, Computational and Modeling Sciences Center, Arizona State University, Tempe, AZ 85287
| | - David J Waxman
- Division of Cell and Molecular Biology, Department of Biology, Boston University Boston, MA 02215
| | - Giannoula Lakka Klement
- Newman Lakka Institute, Floating Hospital for Children at Tufts Medical Center, Boston, MA 02111.
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15
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André N, Carré M, Pasquier E. Metronomics: towards personalized chemotherapy? Nat Rev Clin Oncol 2014; 11:413-31. [PMID: 24913374 DOI: 10.1038/nrclinonc.2014.89] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Since its inception in 2000, metronomic chemotherapy has undergone major advances as an antiangiogenic therapy. The discovery of the pro-immune properties of chemotherapy and its direct effects on cancer cells has established the intrinsic multitargeted nature of this therapeutic approach. The past 10 years have seen a marked rise in clinical trials of metronomic chemotherapy, and it is increasingly combined in the clinic with conventional treatments, such as maximum-tolerated dose chemotherapy and radiotherapy, as well as with novel therapeutic strategies, such as drug repositioning, targeted agents and immunotherapy. We review the latest advances in understanding the complex mechanisms of action of metronomic chemotherapy, and the recently identified factors associated with disease resistance. We comprehensively discuss the latest clinical data obtained from studies performed in both adult and paediatric populations, and highlight ongoing clinical trials. In this Review, we foresee the future developments of metronomic chemotherapy and specifically its potential role in the era of personalized medicine.
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Affiliation(s)
- Nicolas André
- Service d'Hématologie & Oncologie Pédiatrique, AP-HM, 264 rue Saint Pierre, 13385 Marseille, France
| | - Manon Carré
- INSERM UMR 911, Centre de Recherche en Oncologie Biologique et Oncopharmacologie, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Eddy Pasquier
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW, PO Box 81, Randwick NSW 2031, Australia
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16
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André N, Banavali S, Snihur Y, Pasquier E. Has the time come for metronomics in low-income and middle-income countries? Lancet Oncol 2013; 14:e239-48. [PMID: 23639324 DOI: 10.1016/s1470-2045(13)70056-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In 2008, 72% of cancer deaths occurred in low-income and middle-income countries, where, although there is a lower incidence of cancer than in high-income countries, survival rates are also low. Many patients are sent home to die, and an even larger number of patients do not have access to treatment facilities. New constraint-adapted therapeutic strategies are therefore urgently needed. Metronomic chemotherapy--the chronic administration of chemotherapy at low, minimally toxic doses on a frequent schedule of administration, with no prolonged drug-free breaks--has recently emerged as a potential strategy to control advanced or refractory cancer and represents an alternative for patients with cancer living in developing countries. This low-cost, well-tolerated, and easy to access strategy is an attractive therapeutic option in resource-limited countries. Moreover, combined with drug repositioning, additional anticancer effects can be achieved, ultimately resulting in improved cancer control while maintaining minimum cost of treatment. In this Personal View, we will briefly review the rationale behind the combination of metronomic chemotherapy and drug repositioning-an approach we term metronomics. We assess the clinical experience obtained with this kind of anticancer treatment and describe potential new developments in countries with limited resources. We also highlight the need for adapted clinical study endpoints and innovative models of collaboration between for-profit and non-profit organisations, to address the growing problem of cancer in resource-limited countries.
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Affiliation(s)
- Nicolas André
- Service d'Hématologie et Oncologie Pédiatrique, AP-HM, Marseille, France.
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17
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Faivre C, Barbolosi D, Pasquier E, André N. A mathematical model for the administration of temozolomide: comparative analysis of conventional and metronomic chemotherapy regimens. Cancer Chemother Pharmacol 2013; 71:1013-9. [DOI: 10.1007/s00280-013-2095-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 01/14/2013] [Indexed: 02/08/2023]
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18
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Low-dose metronomic chemotherapy: from past experience to new paradigms in the treatment of cancer. Drug Discov Today 2013; 18:193-201. [DOI: 10.1016/j.drudis.2012.07.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 06/28/2012] [Accepted: 07/26/2012] [Indexed: 01/22/2023]
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19
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Liao D, Estévez-Salmerón L, Tlsty TD. Generalized principles of stochasticity can be used to control dynamic heterogeneity. Phys Biol 2012; 9:065006. [PMID: 23197162 PMCID: PMC3618713 DOI: 10.1088/1478-3975/9/6/065006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It is increasingly appreciated that phenotypic stochasticity plays fundamental roles in biological systems at the cellular level and that a variety of mechanisms generates phenotypic interconversion over a broad range of time scales. The ensuing dynamic heterogeneity can be used to understand biological and clinical processes involving diverse phenotypes in different cell populations. The same principles can be applied, not only to populations composed of cells, but also to populations composed of molecules, tissues, and multicellular organisms. Stochastic units generating dynamic heterogeneity can be integrated across various length scales. We propose that a graphical tool we have developed, called a metronomogram, will allow us to identify factors that suitably influence the restoration of homeostatic heterogeneity so as to modulate the consequences of dynamic heterogeneity for desired outcomes.
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Affiliation(s)
- David Liao
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Luis Estévez-Salmerón
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Thea D. Tlsty
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
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Abstract
Complex biological systems often display a randomness paralleled in processes studied in fundamental physics. This simple stochasticity emerges owing to the complexity of the system and underlies a fundamental aspect of biology called phenotypic stochasticity. Ongoing stochastic fluctuations in phenotype at the single-unit level can contribute to two emergent population phenotypes. Phenotypic stochasticity not only generates heterogeneity within a cell population, but also allows reversible transitions back and forth between multiple states. This phenotypic interconversion tends to restore a population to a previous composition after that population has been depleted of specific members. We call this tendency homeostatic heterogeneity. These concepts of dynamic heterogeneity can be applied to populations composed of molecules, cells, individuals, etc. Here we discuss the concept that phenotypic stochasticity both underlies the generation of heterogeneity within a cell population and can be used to control population composition, contributing, in particular, to both the ongoing emergence of drug resistance and an opportunity for depleting drug-resistant cells. Using notions of both 'large' and 'small' numbers of biomolecular components, we rationalize our use of Markov processes to model the generation and eradication of drug-resistant cells. Using these insights, we have developed a graphical tool, called a metronomogram, that we propose will allow us to optimize dosing frequencies and total course durations for clinical benefit.
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Affiliation(s)
- David Liao
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Luis Estévez-Salmerón
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Thea D. Tlsty
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
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21
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André N, Abed S, Orbach D, Alla CA, Padovani L, Pasquier E, Gentet JC, Verschuur A. Pilot study of a pediatric metronomic 4-drug regimen. Oncotarget 2012; 2:960-5. [PMID: 22156656 PMCID: PMC3282100 DOI: 10.18632/oncotarget.358] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Metronomic chemotherapy (MC) is defined as the frequent administration of chemotherapy at doses below the maximal tolerated dose and with no prolonged drug-free break. MC is gaining interest as an alternative strategy to fight resistant cancer. Objective to assess the safety of 4 drug MC regimen in pediatric patients with refractory or relapsing various tumors types. Setting From November 2008 to December 2010, in three academic pediatric oncology centers, 16 children (median age 12 years old; range 5.5-20) were included in this pilot study. This treatment was proposed to children with refractory disease for whom no further effective treatments were available. Most frequent diagnosis were medulloblastoma/cerebral PNET (5) osteosarcoma (5), and one case each of nephroblastoma, high grade glioma, Hodgkin lymphoma, rhabdomyosarcoma, neuroblastoma and kidney rhabdoid tumour. The MC regimen consisted in cycles of 56 days (8 weeks) with weekly vinblastine 3 mg/m2 (week 1-7), daily cyclophosphamide 30 mg/m2 (days 1-21), and twice weekly methotrexate 10 mg/m2; (days 21-42), and daily celecoxib 100 mg to 400 mg twice daily (days1-56) followed by a 2-weeks chemotherapy break. Adverse events were determined through laboratory analysis and investigator observations. Results One objective response was observed in a patient with Hodgkin lymphoma, and 4 patients experienced disease stabilization and continued their treatment for 3 cycles (24 weeks) or more. At last follow-up, 7 patients (43%) are alive including 1 still undergoing treatment. During the overall 36 cycles of treatments received by patients, 4 grade IV toxicities and 24 grade III toxicities were observed in 11 cycles in only 10 different patients. Conclusion The metronomic regimen we report here was well tolerated and associated with disease stabilization. This regimen is currently being evaluated in a national multicenter phase II study.
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Affiliation(s)
- Nicolas André
- Service d'Hématologie et Oncologie Pédiatrique, Hôpital pour Enfants de La Timone, Marseille, France.
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Zapletalova D, André N, Deak L, Kyr M, Bajciova V, Mudry P, Dubska L, Demlova R, Pavelka Z, Zitterbart K, Skotakova J, Husek K, Martincekova A, Mazanek P, Kepak T, Doubek M, Kutnikova L, Valik D, Sterba J. Metronomic chemotherapy with the COMBAT regimen in advanced pediatric malignancies: a multicenter experience. Oncology 2012; 82:249-60. [PMID: 22538363 DOI: 10.1159/000336483] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 01/05/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND The outcome of children with refractory/relapsed malignancies remains poor and novel therapies are urgently required. One of the promising approaches is metronomic chemotherapy. We present the clinical results of 74 children with advanced solid tumors treated according to treatment recommendation with data registry in three European pediatric centers. METHODS COMBAT (Combined Oral Metronomic Biodifferentiating Antiangiogenic Treatment) included low-dose daily temozolomide, etoposide, celecoxib, vitamin D, fenofibrate and retinoic acid. From 2004 to 2010, 74 children were enrolled. RESULTS The 2-year overall survival (OS) was 43.1% (median 15.4, range 1.3-69.9 months). Of the 74 patients, 50 patients (68%) died and 24 are alive: 6 (8%) with progressive disease, 7 (9%) with stable disease/partial response and 11 (15%) in complete response. Median time to response was 6 months. Of 62 patients with initially measurable disease, 25 (40%) had radiological response or stable disease. Fourteen of 25 showing clinical benefit responded within the first 6 months. The treatment was well tolerated on an outpatient basis. Regarding non-hematological toxicity of grade ≥2, hepatotoxicity of grade 3 occurred in 8 children and grade 3 cheilitis in 16 children. CONCLUSION COMBAT is a feasible and effective treatment option for patients with relapsing/refractory malignancies. The treatment is well tolerated with a low acute toxicity profile.
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Affiliation(s)
- D Zapletalova
- Department of Pediatric Oncology, University Hospital Brno, School of Medicine, Masaryk University, Brno, Czech Republic
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Moving forward with metronomic chemotherapy: meeting report of the 2nd International Workshop on Metronomic and Anti-Angiogenic Chemotherapy in Paediatric Oncology. Transl Oncol 2011; 4:203-11. [PMID: 21804915 DOI: 10.1593/tlo.11124] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 05/15/2011] [Accepted: 05/16/2011] [Indexed: 12/21/2022] Open
Abstract
Metronomic chemotherapy, which is defined by the frequent, repetitive administration of chemotherapeutic drugs at relatively low doses, and without prolonged drug-free break, is an emerging strategy to fight cancer. Initially thought to act by targeting tumor angiogenesis, additional mechanisms have been recently unveiled, and metronomic chemotherapy is now considered to represent a form of multitargeted therapy. Despite representing a genuine alternative for advanced and/or high-risk cancer therapy, the development of metronomic approaches in pediatric oncology is still in the early stage. The few numbers of large-scale state-of-the-art clinical trials, issues regarding terminology and the limited understanding of the complex and intertwined mechanisms of action of metronomic treatments have limited progress in this important field of research. On March 18 and 19, 2010, the 2nd International Workshop on Metronomic and Anti-Angiogenic Chemotherapy in Paediatric Oncology was held in Marseille, France, and brought together clinicians, basic scientists, physician-scientists, trainees, and students from all around the world. The main aim of this international meeting was to provide a unique forum to 1) reflect on the major advances that have been made in this field of research since its creation, 2) communicate results from the most recent clinical trials and preclinical studies, 3) discuss the current and future challenges of the field, and 4) set forth a solid framework for future collaborative biologic and clinical studies. The present report documents the main preclinical and clinical data that were presented in the keynote and best abstract sessions and delivers the key messages from the meeting.
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André N, Padovani L, Pasquier E. Metronomic scheduling of anticancer treatment: the next generation of multitarget therapy? Future Oncol 2011; 7:385-94. [DOI: 10.2217/fon.11.11] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Metronomic scheduling of anticancer treatment (MSAT) is progressively gaining interest after the antiangiogenic properties of metronomic chemotherapy and its potential to overcome drug resistance was initially described in 2000. MSAT has now grown beyond the anticipated scope of antiangiogenic chemotherapy, with accumulating evidence demonstrating that these treatments may also act by stimulating an antitumor immune response and could ultimately lead to reinduction of tumor dormancy. An increasing number of drugs, not initially developed as anticancer agents, are currently being used in metronomic protocols in order to increase treatment efficacy. Interestingly, these ‘repositioned’ agents can target cancer cells, the tumor vasculature or, more broadly, the tumor microenvironment. Malignant tumors are no longer regarded as simple congregations of cancer cells but as genuine tissues with various components such as blood vessels, fibroblasts, inflammatory cells and an extracellular matrix. These different components and their multiple interactions play a crucial role in tumor development and response to treatment. Therefore, future anticancer treatments will have to take into account the tumor microenvironment and aim to target the different cellular and molecular participants encompassed in a tumor, as well as their specific interactions. In this article, we explain why MSAT represents a very attractive strategy for developing next-generation multitarget therapies.
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Affiliation(s)
- Nicolas André
- INSERM-UMR 911, Cytosquelette et Intégration des Signaux du Micro-Environnement Tumoral, CRO2, Université d’Aix-Marseille, Marseille, France; Hematology & Pediatric Oncology Department, Children Hospital of ‘La Timone’, AP-HM, Bd Jean Moulin 13885, Marseille Cedex 5, France
| | - Laetitia Padovani
- Service de Radiothérapie, Hôpital pour Enfants de ‘La Timone’, AP-HM, Marseille, France
| | - Eddy Pasquier
- Children’s Cancer Institute Australia, Lowy Cancer Research Centre, University of New South Wales, Randwick, NSW, Australia
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